Republic of the Philippines)

Province of Ilocos Norte )

City of Laoag )

AFFIDAVIT OF LOSS

That I, ADRIANO TOLENTINO, of legal age, Filipino citizen and a resident of Brgy. Guerero,
Dingras, Ilocos Norte, after having been duly sworn to in accordance with law hereby depose and say:

1. I was the owner of a Toyota Lite Ace particularly:

MAKE:_______TOYOTA_____
SERIES:______Lite Ace Van____
MOTOR NO.:______________________
SERIAL/CHASSIS NO.:_______________
YEAR MODEL:_____________________
COLOR:___ Maroon__
PLATE #:__ PTT531___

2. Sometime this April 2017, I transacted the sale of the above vehicle in favor of Mr. Rudy G.
Gante, Deed of Sale which will be executed later. I already received the full consideration for the sale of
said Toyota Lite Ace in favor of Mr. Gante. However, when Mr. Gante demanded for the Certificate of
Registration which I promised to turn over to him, I could not present the same to him as I have honestly
forgot where I kept the said Certificate of Registration.

3. I have been living in the United States of America for a long time and come to the Philippines for
vacation. This time, I decided to sell the said vehicle. I went over-all my files, important documents and
other papers. However, despite earnest effort, same was futile and in vain. Again and again,I search all
places where I could have inadvertently placed the Certificate of Registration but to no avail.

4. By reason of aforesaid premises, I now consider the certificate of Registration covering the above –
said vehicle as lost and beyond recovery. The said Certificate of Registration was not confiscated by
authorities concerned for violation of any traffic rule;

5.This Affidavit of Loss is executed to attest to the truth of the foregoing facts.

IN TESTIMONY WHEREOF, I hereto set my hand this______________________day of

__________________2017 at Laoag City, Iloos Norte.

ADRIANO TOLENTINO
Vendor

SUBSCRIBED AMD SWORN to before me this________ day of _________________2017 at

Laoag City,Philippines affiant exhibiting to me his driver’s license # ___________________________